1. What to do with Anastomotic Stricture Gustavo Plasencia MD, FACS, FASCRS

2. Anastomotic Stricture Etiology Factors contributing Factors contributing Obesity Obesity Ischemia Ischemia Radiation Therapy Radiation Therapy Defunctionalization Defunctionalization Distance from anal verge Distance from anal verge Dehiscence Dehiscence

3. Anastomotic Stricture Etiology Factors contributing Factors contributing Insufficient colon preparation Insufficient colon preparation Inadequate blood supply to colonic or rectal Inadequate blood supply to colonic or rectal stump stump Tension at the anastomosis Tension at the anastomosis Overactive Inflammatory response Overactive Inflammatory response Separation between the two mucosas Separation between the two mucosas

4. Anastomotic Stricture Differ Differ Length Length Luminal narrowing Luminal narrowing Thickness Thickness Time to presentation after the initial surgery Time to presentation after the initial surgery Diagnostic and therapeutic inplications Diagnostic and therapeutic inplications Could be irregular, kinked, and fixed Could be irregular, kinked, and fixed

5. Anastomotic Stenosis Categories Categories 0 no evidence of stenosis 0 no evidence of stenosis 1 endoscopic or radiologic stenosis no symp. 1 endoscopic or radiologic stenosis no symp. 2 symptoms requiring endoscopic dilatation 2 symptoms requiring endoscopic dilatation 3 symptoms requiring surgical corrections 3 symptoms requiring surgical corrections

6. Anastomotic Stenosis Symptoms Symptoms Constipation (bm < 3 times per wk) Constipation (bm < 3 times per wk) Abdominal pain (> 1 h 3 times a day) Abdominal pain (> 1 h 3 times a day) Increased defecation (> 4 times a day) Increased defecation (> 4 times a day) Incontinence Incontinence

7. Predictive Factors of Stenosis after Stapled Colorectal Anastomosis Prospective analysis of 179 patients Prospective analysis of 179 patients Anastomotic stricture defined as the inability to pass a rigid sigmoidoscope through the anastomosis Anastomotic stricture defined as the inability to pass a rigid sigmoidoscope through the anastomosis Mean age 59.3 years (20-91) 85females, 94males Mean age 59.3 years (20-91) 85females, 94males Cancer 59% of patients Cancer 59% of patients Stenosis 36 patients (21%) Stenosis 36 patients (21%) Bannura et al: WJSurg Sept. 2004 Bannura et al: WJSurg Sept. 2004

8. Predictive Factors of Stenosis after Stapled Colorectal Anastomosis Prospective analysis of 179 patients Prospective analysis of 179 patients Parameters study Parameters study Age, Sex,Indications for Surgery,Height of the Anastomosis,Size of Circular Stapler,Type of Circular Stapler,Type of Anastomosis,(single vs doble),Proximal Stoma,Technical intraoperative defect,Complication with anastomotic fistula Circular Stapler,Type of Anastomosis,(single vs doble),Proximal Stoma,Technical intraoperative defect,Complication with anastomotic fistula Bannura et al: WJSurg Sept. 2004 Bannura et al: WJSurg Sept. 2004

9. What to do with Anastomotic Strictures.Predictive factors of stenosis Prospective analysis of 179 patients Prospective analysis of 179 patients Anastomotic stricture defined as the inability to pass a rigid sigmoidoscope through the anastomosis Anastomotic stricture defined as the inability to pass a rigid sigmoidoscope through the anastomosis Mean age 59.3 years (20-91) 85females, 94males Mean age 59.3 years (20-91) 85females, 94males Cancer 59% of patients Cancer 59% of patients Stenosis 36 patients (21%) Stenosis 36 patients (21%) Endoscopic dilatation required in 8 pts. (4.5%) Endoscopic dilatation required in 8 pts. (4.5%) Bannura et al; WJSurg. Sept. 2004 Bannura et al; WJSurg. Sept. 2004

10. Predictive Factors of Stenosis after Stapled Colorectal Anastomosis Prospective analysis of 179 patients Prospective analysis of 179 patients Stenosis Affects 20% of the pt’s less than 5% need any treatment Gender male patients Gender male patients Time interval between surgery and endoscopic evaluation This complication depends on the process of cicatrization which individual and unpredictable Bannura et al: WJSurg Sept. 2004

11. What to do with Anastomotic Strictures? Prospective study on 68 patients, 22 (32%) post- operative symptoms of anastomotic stenosis. Prospective study on 68 patients, 22 (32%) post- operative symptoms of anastomotic stenosis. 12 (17.6%) needed dilatation 12 (17.6%) needed dilatation median diameter of stenosis 7mm median diameter of stenosis 7mm 8 patients, one session 8 patients, one session 3 patients, two sessions 3 patients, two sessions 1 patient, three sessions 1 patient, three sessions Ambrosetti, et al DC&R, May 2008 Ambrosetti, et al DC&R, May 2008

12. What to do with Anastomotic Strictures Therapeutic Options Transanal Dilataion: manual/bougie Transanal Dilataion: manual/bougie Microwave coagulation therapy Microwave coagulation therapy Transanal incision with argon laser Transanal incision with argon laser Plasma coagulation therapy Plasma coagulation therapy Transanal ballon dilatation Transanal ballon dilatation

13. Stapled revision of complete colorectal anastomotic obstruction General anesthesia in the modified lithotomy position General anesthesia in the modified lithotomy position Laparotomy and the stictured anastomosis identified Laparotomy and the stictured anastomosis identified 2cm longitudianal colotomy to place anvil of a 29 mm circular stapler 2cm longitudianal colotomy to place anvil of a 29 mm circular stapler Base of instrument placed through the rectum and spike is advanced under direct vision through the strictured area Base of instrument placed through the rectum and spike is advanced under direct vision through the strictured area

14. Stapled revision of complete colorectal anastomotic obstruction The anvil is then placed in the proximal colon via the colotomy and connected to the spike The anvil is then placed in the proximal colon via the colotomy and connected to the spike The stapler is fired, excising the stricture completely The stapler is fired, excising the stricture completely Sigmoidoscopy is conducted to confirm the integrity of the anastomosis and adequate lumen R.McKee; et al. A J of Surgery 2008 Sigmoidoscopy is conducted to confirm the integrity of the anastomosis and adequate lumen R.McKee; et al. A J of Surgery 2008

15. Transanal Treatment of Strictured Rectal Anastomosis with a Circular Stapler Device General anesthesia patient in lithotomy position General anesthesia patient in lithotomy position Anvil introduced proximal to the stricture with a long clamp Anvil introduced proximal to the stricture with a long clamp The base of the instrument pass through the rectum The base of the instrument pass through the rectum Introduction placement and tightening of the stapler perform under fluoroscopic control Introduction placement and tightening of the stapler perform under fluoroscopic control Final result, check with gastrographin contrast Final result, check with gastrographin contrast

16. Transanal Treatment of Strictured Rectal Anastomosis with a Circular Stapler Device 3 patients 3 patients No complications No complications Discharge home, first post-operative day Discharge home, first post-operative day No recurrence of stricture at 8, 12 and 14 months No recurrence of stricture at 8, 12 and 14 months M. Pabst; et al M. Pabst; et al Digestive Surgery Digestive Surgery March 2007 March 2007

17. Results of Reoperations in Colorectal Anastomotic Strictures Study of 27 patients Study of 27 patients 78% of pt’s had post-operative leak 78% of pt’s had post-operative leak Median time between surgery and diagnosis 7.2 months (1-24 months) Median time between surgery and diagnosis 7.2 months (1-24 months) Locations at a mean distance 9.5 cm (4-15 cm) Locations at a mean distance 9.5 cm (4-15 cm) Surgery performed 7 colorectal anastomosis and 20 coloanal anastomosis Surgery performed 7 colorectal anastomosis and 20 coloanal anastomosis Intestinal continuity restored in all cases Intestinal continuity restored in all cases Schlegel; et al DC&R Oct. 2001 Schlegel; et al DC&R Oct. 2001

18. Efficacy and Safety of Endoscopic Balloon Dilation of Benign Strictures after Oncologic Anterior Rectal Resection 24 Patients 24 Patients Dilatation using through the scope balloon technique Dilatation using through the scope balloon technique No procedure related complications No procedure related complications The mean number of sessions required was 2.3 The mean number of sessions required was 2.3 No relation between sessions and recurrence No relation between sessions and recurrence Dilatation successful in 22 patients Dilatation successful in 22 patients Araujo and Costa; SLEPT Dec. 2008 Araujo and Costa; SLEPT Dec. 2008

19. Stapled revision of complete colorectal anastomotic obstruction General anesthesia in the modified lithotomy position General anesthesia in the modified lithotomy position Laparotomy and the stictured anastomosis identified Laparotomy and the stictured anastomosis identified 2cm longitudianal colotomy to place anvil of a 29 mm circular stapler 2cm longitudianal colotomy to place anvil of a 29 mm circular stapler Base of instrument placed through the rectum and spike is advanced under direct vision through the strictured area Base of instrument placed through the rectum and spike is advanced under direct vision through the strictured area

20. Anastomotic Stricture

21. Striture Dilatation

22. Reinforced Anastomosis

23. Perforated Stricture Dilatation

24. Stented Stricture

25. Perforated Stent

26. Conclusion Sricture is uncommon ocurrence after colon and rectal anastomosis Sricture is uncommon ocurrence after colon and rectal anastomosis Treatmeant varies depending of the nature and location Treatmeant varies depending of the nature and location Usually ballon dilatation effective, stents use as other alternative Usually ballon dilatation effective, stents use as other alternative Surgery reserved for failed less invasive treatmeant or complications of the above Surgery reserved for failed less invasive treatmeant or complications of the above